@layout("/common/_container.html"){


<div class="ibox float-e-margins">
    <div class="ibox-content">
        <div class="form-horizontal" id="whiteShopApplyInfoForm">
            <div class="row">
                <div class="col-sm-6 b-r">
                   <#input id="user_name" name="姓名" underline="true" />
                   <#input id="recommendation_no" name="推荐人推荐码" underline="true"/>
                   <#input id="flow_no" name="缴费回执号" underline="true" />
                   <#select id="pay_type" name="支付方式" underline = "true">
                         <option value="">请选择</option>
					     <option value="3">线下</option>
					     <option value="5">其他</option>
				  </#select>
                   <#input id="pay_time" name="缴费时间" underline="false" type = "text"/>
                </div>
                <div class="col-sm-6">
                    <#input id="binding_phone" name="绑定手机" underline="true" />
                    <#input id="pay_money" name="实付金额" underline="true" />
                    <#input id="pay_channel" name="支付渠道" underline="true" />
         
                </div>
            </div>
            <div class="row btn-group-m-t">
                <div class="col-sm-10">
                    <#button btnCss="info" name="提交" id="ensure" icon="fa-check" clickFun="WhiteShopApplyDlg.addSubmit()"/>
                    <#button btnCss="danger" name="取消" id="cancel" icon="fa-eraser" clickFun="WhiteShopApplyDlg.close()"/>
                </div>
            </div>
        </div>

    </div>
</div>
<script src="${ctxPath}/static/modular/packback/white_shopApply/white_shopApply_info.js"></script>
<script src="${ctxPath}/static/js/layDate/laydate/laydate.js"></script>
<script>
    laydate.render({
        elem: '#pay_time' ,
        type: 'datetime'
    });
</script>
@}
